Ortona Italy

One year ago today my wife and I were walking the streets of Ortona Italy, the town on the other side of the world where my grandfather Eduardo Pantaloni grew up. Then we hadn't even yet conceived of the little boy (Eduardo's great-grandson) who I hold in my lap as I write now.

I think of Eduardo (who changed his name to Edward when he immigrated) growing up in Ortona and my little son growing here in my lap. Eduardo died on Christmas day when I was only a little boy. One of my strongest memories is of him telling me about the beautiful farms in the seaside village were he grew up, only a few days before he died.

He has been dead for decades now, and no one in his home town remembers his name. He is even a distant memory to me. It makes me realize that even though I am 30 now I will also someday be gone and forgotten even in the places that were once my home.

This makes me glad that I am a father. My son may not know it now but his great-grandparents who will only exist in his mind as black and white photos have left themselves in my wife and me, and thus their lives project into his own. Similarly I will leave myself in him.

Death & Christmas

This is a poem I wrote in Haiti after watching a newborn baby (the one in the picture) die. I hope it doesn't lessen your joy of Christmas, but perhaps deepen joy with a perspective we all need: the understanding that our hope was bought with a price.

The Incarnation

Why did I ever come forth from the womb to look on trouble and sorrow, so that my days have been spent in shame? -Jeremiah 20:18

Unto us a child is born
Unto us a son is given.
Born of blood,
Born to bleed.
Born into the cold
Born into squalor
Among the filth of animal feces
On the coldest night of the year
Night air carries distant moaning,
The bitter moaning of death vigils.
Many die on such a night.

...and the bloody infant
Miserable yellow jaundice.
Wrap the infant tight,
Lay him shivering in the hay
To be bitten by lice and fleas
And bored through by parasites.
He whines and writhes,
Vomits, then shakes in quiet agony
But the child will not die tonight...

He will live to know more agony
The suffering life of a dirty peasant,
Building with broken hands.
Born of suffering,
Born to suffer.
And pitiful, muffled cries draw
Men of the fields,
ugly and reeking,
Bringing infection to the infant.
Unto us a sickly child is born,
Unto him the plague is given
And the infection of us all
Will be upon his shoulders.
But the wretched one will not die tonight...

He will live to know more agony
To die tormented and alone,
Rather than here in his mother’s arms.
Brought to life this night
Brought to life to die.
In the wretchedness
Of this yellow, shivering body:
Here is the only hope
Of peace and salvation.

Unto us a sickly infant is born.
Through suffering hope is born.
And the weight of the world
Will be upon his shoulders.
And Death will be upon his shoulders
Tremble before your newborn Savior.

…and the Word became flesh, and dwelt among us.


*

Memento Mori

This is a picture of some interesting graffiti I saw in Europe. Memento Mori is an ancient practice of constantly reminding yourself that you will die. To our modern tastes this seems morbid, but medievals believed the thought of their own mortality would make them live life better. Now we are encouraged not to think of death, or to think of it in euphemistic terms.

Even as someone who works with death I am surprised at how I go about my life as if I will never die. While avoiding death is universal to all creatures, shunning even the thought of our death is unique to our culture. It reminds me of a fascinating quote I read while at L'abri:

“Today... death has become a taboo: nobody must tell the dying man the he must die, and the funeral cosmetics put the mask of life on the corpse. For us the natural processes of decay have become just as shocking as as the natural processes of copulation and birth were a century ago. Our great-grandparents said that babies were found under cabbage leaves or were brought by the stork. Our children will probably say that those who have 'passed away' are changed into flowers or are sleeping somewhere in a beautiful garden... Man can no longer cope with his finitude.”

-Helmut Thielicke

The Blind Mechanic

A few weeks back, I saw a very thin man being wheeled into the ER. I nodded toward him and smiled. He nodded back. He was not my patient so I went back to work on my own patients. About an hour later I noticed the monitors and said to a nurse, “You should check him, his pulse is dropping.”


The nurse looked up, “Oh, that's okay. He's dying. Terminal cancer, he just came in for pain control. He's comfortable now, so we're letting him die with his family.”


I noticed several young women around him who I assumed to be his daughters holding the man's hands. “Overall not a bad way to go, painless and being loved,” I thought and returned to my work.


Physicians see death so often that it becomes familiar. We are Mechanics of life and death, tinkering with the machinery of the body everyday. We intervene to keep the machine running, but eventually the mechanism always becomes unstable and breaks down.


Contrary to what you might imagine, doctors have no deepened understanding of death.


Doctors talk a lot about their own deaths, but not like you might talk about it. They don't discuss the meaning of death, or how it makes them appreciate the beauty of life. Seeing so much death, doctors mentally amass large collections of different ways people die. Doctors discuss the pros and cons of different ends to life, like other people might debate which car or computer is best: “Not a bad way to go.” “I hope I don't go like that.” “I want to go quickly.” “No, I want to go slow so I can set things in order.” “I want to feel nothing, just load me up with pain meds.” “No I don't mind hurting some so I can be aware of my family visiting me.” “I won't let them run a code on me if I'm old.” “I would prefer a sudden heart attack, dead before I hit the ground.” “No, I want to fade into dementia and never know what's happening.” “Renal failure isn't so bad a way, you just fall asleep and don't wake up.” We actually have such conversations, pulling various deaths from our collections and comparing them. Since we tinker with the mechanism of death we think we understand it.


Doctors mistake familiarity for understanding. We mistake the end of our job for the end of the matter.


Even we physicians of faith often think like nihilists. I struggle to remember that I know more than what I see. Every time I recite the Apostle's Creed I affirm that “I believe in the resurrection of the dead, and the life everlasting.” Still I must tear these blinders from my eyes to see with the eyes of faith. My perspective is limited, and my blinders that help me in my work sometimes make me blind. There is so much more to life and beyond life than this these faulty machines and ways the are repaired or broken.


*Note: information about the patient mentioned above is intentionally inaccurate to protect identity and privacy.

The Execution of Saddam Hussein

Saddam Hussein was executed for crimes against humanity last night. Certainly Hussein is an example of the worst sort of criminal, but I cannot help but feel this was pitiful and unnecessary. None of the evil things he did are undone by his execution. He would have died eventually and answered to God for his sins without us taking his life.

In my job I see a lot of people die. I watched a man die at the hospital yesterday. My response to the news was the same as I felt in the hospital: Sorrow. Even with my political opposition to the death penalty, I had not expected to be saddened by the death of someone as horrible as Hussein. I suppose my eyes are too full of seeing death. I want no part in killing, even those who “deserve death.”

Loss, 9/11, and David

David died of metastatic bone cancer just a few days after the September 11^th bombings. All the grief over the killings will always be bound in my mind to the loss of David. I wrote this the day he died:

Dear David,

You died today at 6 am. I was planning to write you. I have always been planning to write you –ever since you gave me your address when you left. I hope you didn’t mind. We were never very close, but I wish I had a chance to tell you that I admired you. I remember that afternoon when I asked how the doctor’s visit had been. You told me that it was cancer. “Oh,” I said, “but not a serious cancer is it?"

“Very serious,” you replied. I was amazed that a 17-year-old could make such conversation without hesitation. You didn’t put on a false bravery either; you admitted to us that you were afraid. I would have been more afraid than you. I would have been angry if my future had withered just as I was reaching manhood.

I remember the last night you were at Covenant. You and the guys from the dorm came over to my house. We read poems. Your poem was beautiful. You wrote it long before you knew there was a cancer in your bones. You wrote about being lonely. You wrote about sitting alone when everyone else sat with friends. You wrote about being afraid to talk to girls. You wrote about your faith in God. I was amazed at you. I was amazed at the peace you found in loneliness, and how grateful you were. You were grateful that the guys at Catacombs had made you feel welcome and loved. You were grateful for the three months you got to spend with us here. You were even grateful for the cancer that you couldn’t understand. We all just sat around the fire and laughed and read each others poetry. Before you left we all took a picture together. You didn’t smile. You didn’t frown. You just looked right at the camera while the rest of us clamored and grinned.

You faded suddenly. For the last two years all I heard was good news. You were feeling strong. Your chemotherapy was going well. And then suddenly one day all the news changed. You were dying. You had perhaps a month left. Fernando told me about seeing you. He said you looked weak, but as always you were kind and resilient. You said that you take it one day at a time. I wish I could have gone to see you. I wish I could have put my arm around you and said, “Courage. Take courage.” I wish that I had written you a letter. I planned to write someday just to let you know that you were in my thoughts and prayers, but you died too quickly.

I know you are at peace. You see the face of God. But I cannot help but feel angry for you. Angry that you went so early… angry that you will never fall in love, graduate from college, make love to a woman, have children. All the things I have in life anger me right now because you will never have them. Your death came at the time everyone was mourning for thousands of people who died in New York. They died in falling buildings, and the whole world cried for them and vowed revenge. You were dying too but no one noticed. You had no woman who loved you, no children, no close friends to mourn you. Due to the timing, your family’s mourning is likely lost in the national paranoia. I wonder if any of us at all will be thinking of you 10 years from now when we all have wives, children, and lives of our own? I am angry at myself that I never wrote you. You gave us all your address when you left. I was never a close friend, but did you have many close friends? I thought of you often, up north in some lonely oncology ward. You would have taken comfort in letters from one of your friends from college. And you might have shared your wisdom with me. I would have known how to mourn you better because I would have known you. But I was always too busy, always planning to write you later. Now you have died, and I am mourning that I did not know you. I realized long ago that you were wise and lonely. I should have been a friend to you. I think you needed friends. I hope that when I die, that I have friends. But you died too young, and we who are young forget too quickly… too quickly to hold on to a friend over 2 years of chemotherapy.

I wonder if you died alone. Was everyone who should have been focused on you too absorbed in the news of bombings and war? I hope no one told you about it. I hope you slipped away without the thought of the whole world—the world that needed the wisdom and kindness that you would not live to bestow—mourning thousands of dead New Yorkers, never knowing that you were dying alone or that you even ever lived. But you are no longer lonely, you know the presence of Jesus our Savior. I am the one who is lonely. I am here thinking of you and crying. Did I tell you that I cried when I heard you were dying? I had not cried in many years. I didn’t even cry when I heard about the thousands of innocents killed last week, but I cried for you. I cried that you died so young. I cried that I could never know you as I had wished I could two years ago when we spoke at my house.

I know that heaven is a better than here. I know that death does not have the final victory, but it is a chasm between us. You know longer have the possibilities of this life, the books you hoped to write, the women you longed for, the friends you needed, the wisdom you wanted to share. I must live my life better. You give me wisdom even in death. I will join you in death someday, and it will be better there, but for now I will live my life better. I will live and love better for all the life and loves you missed.

Death and The Doctor

I had a lot of patients die recently and it was weighing heavily on my mind. It is interesting where your thoughts go when you sit down and start writing:

In the hospital again. Lots of death is always here. Watched a 2 year old girl whom I had delivered, slowly die. Nothing I tried worked. She faded right in front of me while her mother cried. For a while I had dreams about her. I would wake up frantically trying to save her only to realize the child had died a week before. Later on call, I ran a code on a woman for almost an hour. All her ribs broke. We shocked her again and again but nothing worked. Then the other day I sent a gentleman I have cared for several years to hospice. I always liked him, although he never cared for doctors. He said he was tired of treatments and check-ups and was ready to die.

Working in medicine is an odd job. I can think of no other role that brings one so close to death without any real danger involved. Soldiers or law enforcement put their own lives in danger in their jobs that involve for life and death, but the doctor or nurse almost never fears harm. Other than the occasional cold caught from a patient and being kicked by a drunk patient I have never experienced any physical harm or danger in medicine. Doctors are like the television-watchers who absorb violence after violence from the safety of a living room. We may struggle to save our patients or mourn them when they die, but in the end we are observers and not participants in the suffering we see. I wonder if it is healthy for the mind to see death so often and have no immediate threat of it to force fear in us?

I have often noticed that soldiers and police officers I encounter seem cool and distant, but their experience with death is different. They have known their own lives to be in danger. The modern hospital may be a unique place in society where those who intimately interact with life and death are immune to being harmed. (In some ways even literally immune; I get more vaccinations than the average person.)

I wonder if there are threads of voyeurism in our desire to help the suffering? It is a job that must be done, and we are proud of our opportunity to "help people," but we are not the ones who would be just as contented helping people from a distance or even helping those we might never see. We want to help from up close where the blood and crying is.

I didn't consciously recognize this in myself when I chose medicine as a career. However, I cannot deny that when I run to a code it is not only altruism that drives me. I want to be where the action is. I suppose this is the same instinct that keeps us glued to news broadcasts of wars and plane crashes.

There is something in us that seeks to watch death and suffering. Perhaps we seek catharsis—to somehow improve our souls by empathizing with the suffering of others. At least I hope it is reflection and improvement we seek.

Watching Someone Die

I watched a woman die a few weeks ago. I wrote about it in my journal. (All personal identifying info about her has been taken out.) Here it is:

I have never seen anyone die so fast. One minute she was awake and crying in pain and fear; then a moment later she was dead. It is so strange that after years of being in medicine seeing a death would shake me so much. Usually I see people die slowly and see it coming far in advance, either that or I am called to a "Code Blue" when the body is already in collapse and thus a person's death is just a mechanism that I am combating. This woman is the first person I ever watched die suddenly and unexpectedly.

When the nurse called me saying she was having chest pain, I knew I needed to get there quickly since she was old and had a known heart problem. But she was in the hospital for an unrelated problem. I didn't imagine I would be the last person she would ever see. She was afraid. I think she realized she was dying before I did. In retrospect, I'm glad that I took a moment to take her hand and tell her we were going to take good care of her. I did take good care of her. I did everything right, but nothing worked. I had been with her only a couple minutes when I saw the EKG waves change on the monitor above her bed. Only then did I realize how bad the heart attack was. Most of her heart muscle had just quit. I ordered the nurses to give medicines and get equipment but none of it was any use. I remember asking, "Maam, please take a deep breath" and realizing she wasn't breathing at all. The nurses and I felt for a pulse, but it was gone.

She had a DNR (Do Not Resuscitate) order. Part of me wished I could run a Code Blue, not that I could have made any difference in someone her age with a heart so severely damaged. I was glad that I wouldn't have to hear her ribs crack with chest compressions, but in some secret way a Code would have helped me. It would have given me a chance to keep working, to keep analyzing the mechanisms of her cardiovascular collapse.

Without work to do all I could do was watch her; watch as the pink warm flush went out of her cheeks. I could only look a her as a person: a woman who thirty seconds earlier I had told not to be afraid. A woman who had lived and loved and feared for many years that had suddenly ended. Looking at her as a person is frightening when she is a stranger who has just died under my care. I never even knew her, but I loved her then, because I thought no one should have to die without someone who loved them there. I almost cried in front of the nurses.

I closed her eyes, and pronounced her dead. Before that night I had always thought the idea that life is "fragile" was a bit of an overstatement. I had been amazed at how stubbornly the dying body could cling to life. As I watched her die I realized how fragile it could be. It was just one breath between her pleading look to me and the blank eyes that I saw when I asked her to take another breath that she could never take. She was gone in a second.

I helped the nurses clean up. We removed all the medicines and oxygen tubing and pulled the sheets back over her. I straightened her hair out of her eyes. I wanted her to look beautiful for her family when they arrived. As my hand was on her forehead I silently repeated the blessing:

"The Lord bless you and keep you,
The Lord lift up His countenance upon you,
And be gracious to you.
The Lord cause His face to shine on you,
And give you peace."

It is a blessing Christians have spoken to each other for centuries. I only realized now that it is about heaven.


(Click Here to Subscribe to the Gridbook Blog)